Patients can use a copay card or coupon to help cover the cost of the drug, but the payment does not count toward their insurance plan’s deductible or out-of-pocket maximum. Insurers and pharmacy benefit managers like CVS Caremark and ExpressScripts have begun refusing to use copay cards as the drugmakers intended.ĬVS Caremark introduced “copay accumulator” programs two years ago. California passed a law last year limiting their use and federal litigators have increased scrutiny. Insurers and lawmakers have begun to push back against the popular copay programs, saying they raise the cost of medications in the long run. ![]() This approach will “create a new black hole of patient-directed payments and avoid any scrutiny,” he said. “All of these programs try to help patients afford the medications,” said Totonis, whose company bought PSKW, which issued the check Burgess received from Amgen in 2017.ĭaniel Nam, executive director of federal programs for AHIP, the America’s Health Insurance Plans, said direct reimbursement using checks is just another way for manufacturers to make insurance companies pay for expensive drugs, which helps jack up monthly premiums. He declined to confirm the average value of the checks or name the drugmakers that issue checks via ConnectiveRx. Harry Totonis, chief executive of ConnectiveRx, a pharmaceutical services company, said sending checks to patients is “not a commonly used practice” and happens “a fraction of 1 percent” of the time. While Amgen’s primary assistance is through copay cards, “in some instances, based on patient preference, Amgen will provide direct reimbursement” after a patient has already paid for the medicine, Amgen’s Kristen Neese, director of corporate affairs, said in an emailed statement. When the cards fail to work, for whatever reason, Amgen can send direct reimbursement. The federal anti-kickback and Stark laws were meant to prevent bribery of patients and doctors and do not apply to private commercial insurance plans.ĪbbVie, which makes the blockbuster arthritis drug Humira, will send a check if patients can prove their copay card doesn’t work for a variety of reasons, said Adelle Infante, director of external communications for the company.Īmgen, the maker of Burgess’ arthritis medicine, provides up to $12,000 of copay assistance each year to commercially insured Enbrel patients who need help meeting out-of-pocket expenses, often regardless of the patient’s financial status. “You can accept cash from anybody as long as it’s not a government program,” Schiffbauer said, noting there may be income tax obligations for the patient. ![]() ![]() The practice of sending checks is legal as long as the patients are not enrolled in government-funded insurance such as Medicare and Medicaid, said William Schiffbauer, a Washington, D.C.-based health insurance attorney.
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